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HomeMy WebLinkAboutFOREST RIDGE BLK 1 LT 1BForest Ridge Block 1 Lot 1 B #017-113-12 Municipality of Anchorage Page of Z DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: G 1 � � PID Number: Or --I I?= }! Named I p � 1 J� Wastewater System: -ii -New ❑ Upgrade Address_ _ F.PrSrt,.l oo'D l�cY�'6 ABSORPTION FIELD Phone: No. of Be rooms: p Deep Trench ❑ Shallow Trench ❑ Bed— Mound ❑ Other LEGAL DESCRIPTION Soil Rating: � Total Depth from original grade: / • J GPD/S FI Lot: Block: Subdivision: Depth to pipe bottom from original grade' Gravel depth beneath pipe Ft 0• Ft Township: Range: Section: Fill added above original 9, e:0 i FI Gravel length: �./j/ N Ft WELL ew ❑ Upgrade Gravel width:/ 9"t. Numb of lines: Di stance be linen Ft Ft Ilcatlon (Privvaate.. A.B.C): Total Depth: tOI Cased To: IOI Total absorption area: tw Pipe materiel: r Ft. Ft. I2�LY SO Ft Driller: Oa ;D-zllo Static water Le vel: IS Installer: Date installed: t,�til�'�Q�\.L.\ -!1. -1�7 Ft. Yield: ZOGPM Pump Set at: LA V___ Casing Height Above Ground. TANK Ft I'L'k Ft. SEPARATION DISTANCES El Septic ❑Holding T.E.P. To Septic Absorption Lih Holding PubkoPrivate Manufacturer: Gspecify In gallons: From Tank Field Slalion Tank Sewer LiMS t �J Well 1051 Imo✓/ Io5 / irk 1� !f--' Material _� 4�rG Number of Compartments: 16bk IGS=!•- Ic`-I' — LIFT STATION Water Lot Line Lf gj ` I D ! �`I — SIze in I al� s: MaIGe•Fi'C-iri Foundation / t7 y "Pump on" level at: 'Puma rev el at: High water alpirm at: Curtain �_ pump Make &M Electrical Inspections performed by: Drain Remarks: BENCH MARK 1�6'l©V15 I Locat on and Description Assumed Elevation: t I - ENGII_NEEE'S SEAL .� ••-; '.."'tie r.�(. %fe `Tr •i,r ti S d. S ENGINEERING by: River LOOP Raid, tba: 1si'�7,..���z1 _. i' ` �� • .. .... ,.`...".". .e... , Inspections performed JZ0341ke Eagle R ivu'e Alaska "577 2nd 4� ..:........ « , .. +�� :• ben A. 8'+a ow Department of Hea and Human Services approval De P�`'�P�o�E3s~'�%� up. Reviewed by: Date: 30 - and approved IV 72-017 (Rev. 9/91) MOA 25 Permit No. SW930042 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description: FOREST RIDGE SUBDIVISION, BLOCK 1. LOT 1 PID No.: 01711274 r Tomo. � erm Nr or ' 9o.oe Cot CO 121.1' Page 2 of r 9wunox ORAD6 99.7 WH ILLTR I�9wC WPWQA®i M10®1 SNAmw 118.7' r oN,o roan 118.2' 95.3' 1'� GN- 95.3' 118.2' ITor. oT NO WATER FOUND 103.2' N.T.S. A B 00' WELL C01 15.5' N WELL MH MTI- MT2 110' 70' MT3 MT4 100' 75' DRIVE NEW PRESS. DIST. BE NEW 4 BDRM B HOUSE \ \ col NEW 1500 C S.T.E.P.SYSTEM \ •an C ENGINEER'S SEAL sw.w.- .1.. • l� e A" ar 51n T2-013 A "I) MOA 25 COLONY- BUILDER,S.rf91w0t7 3415 6934 � P.O� ' -il �•'•'^ . {, 1.0 A P`', ..P •,.'ti J}.... ::. , ' yI i'! )��:�.} �:•.�. ... ,: ' - . _i1�8PEGT I0N RRPpRr j; •.T.'- A, ..�, : , ""r y .•: 1 ..'tOi�t :C,q"q CKMCUg)O}IOGgIllPtAtCE.�IATq YR_„rQNFP-.g;A6NGQt^NCOtlRk AGEY � ■BP UItL7:DCISC tTR}) 'i•',p' GgsnC'Rbi:Iq VMRIS�IoOftNP ',ETY. 3560.EAET TUDOR ROAIORMa7I0N«ti' -<-I9�q, 0O7O)7G - 8 G3-349 Aim, (907)SIlNSf PERMIT _ :.93-0161_. NAME- COLONY 3'BLD _ '-= PHON£ 4:,244-6233 ADDRESS:c5301%BISHOF CASTLE —DATE,1/1993=7 LOT: LOT: 1 BLOCK: I SUBDI FOREST RIDOE --- -_- COMMCNT:,' L=K BOX C.O.L. «-- --------- TYPE INSPECTION! ELECTRICAL FINAL ----- - -'«-« -` --- 0 0 -- . - --.-. • ______� ___- EV NOl14ONCOMPLIANCE OBSERVED E13 CORRECTIONS ESSEN- TIAL AS EXPLAINED BELOW :' ti ;•.. E..]_uILL-REEXAMINE AT NEXT INSPECTION E 7 DO-NOT.CONCEAL-UKTIL'RSINSPECi9D ----------------- «---------- «--_«------------- -,- _-_-- ----------i .. COMMENTS: Irl eG-P21 C "•r F M 1'. • AMv !.� 't "YLBABEAiL°OR INGPEGTxONt fF 1 i LOCATION OF WELL STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES DIVISION OF WATER WATER WELL RECORD BOROUGH 6UBDNWON LOT BLOCK SECTION OTRS SECTION TOWNSHIP Mq MEPoOIAN L j ON Or�s1 1�iV t. ❑S LOCATIONlSKETCH: WELL OWNER: 17 /� DEPTHS MEASURED FROM:)qcasing top ❑ground surface WILL DEPT • IDATE OF COMPLETION Depth of hole: ft '/ Depth of casing: N J Z— 15-7 BOREHOLE DATA: Depth Material Type and Color From To DEPT TO STATIC WATER LEVEL: Sj tt below] top of easing ❑ground surface Date: "/ J / Z- !' n �1 I t� ,J! METHOD OF DRILLING: Ci air rotary ❑ cable tool ❑ other USE OF WELL: M domestic ❑ irrigation ❑ monitor / 1 ❑ public supply ❑ other f �n CASING STIC - P_ it- Diam• G in. to/O/ ft %/J a At / z ✓�l rn� �/ Casing type!in. to v/ ft WELL INTAKE OPENING TYPE: open end ❑ screened ❑ perforated ❑ open hole Depths of openings: to it SCREEN TYPE: Diam: in. Slot/Mesh Size: Length: ft GRAVEL PACK P6 Volume used: Depth to top: D GROUT TYPE: Volume: Depth: from ft to It JUN 27. 1993 DEVELOPMENT MET OD: e-1 Muni Duration: `P eafth & w'Qfa an Sery e es PUMPING LEVEL AND Y ELD: lot% ft after fus pumpirq gO gpm PUMP MAKE DEPTH: It Horsepower. WELL DISINFECTED UPON COMPLETION7 O YES ❑ NO CONTRACTOR INFO#MATION: REMARKS: PLEASE MAIL WHITE COPY OF LOG TO: 'lam /��� yj ONR/DNISION OF WATER zedeslf p�esrtativeatlS a PO BOX 772116 EAGLE RIVER AK 99577-2116 5;., MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES k� P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW930042 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:NORCOL INVESTMENT OWNER ADDRESS:3911 EASTWOOD, LOOP ANCHORAGE, AK 99504 PARCEL ID:01711274 LEGAL DESCRIPTION: FOREST RIDGE BLK LOT SIZE: 42885 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 PAGE 1 OF 1 DATE ISSUED: 3/31/93 EXPIRATION DATE: 3/31/94 V16;In, ,o,Qo ,/, 4 ea 9-93 - 2'A�w 1 LT 1 sfs 9 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: ISSUED BY DATE: DATE : `� ✓// ak4 R March 25, 1993 ROBERT SHAFER. P E ROGER SHAFER. P.E. CIVIL ENGINEERS (907) 694 FAX 694 1211 HEALTH AUTHORITY Municipality of Anchorage APPROVALS DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 'LF Street P.O. Box 196650 Anchorage, Alaska 99519-6650 SEWER WATER MAIN EXTENSIONS REFERENCE: Forest Ridge Subdivision, Block 1, Lot 1 SEWERS WATER INSPECTION Request you issue a permit to drill a well and install a septic system to serve the proposed four bedroom house on the referenced property. ENGINEERING STUDIES ANDREPORTS Two test holes were excavated and percolation tests performed. The approximate locations of the test holes are located on the attached site plan. The monitoring tubes within the holes have been checked; test hole 11y was found to be dry and water WELLINSPECTION I FLOW TEST was found at 101 In test hole 12 . This property has enough area for a septic upgrade which can be seen on the attached site plan. We do not anticipate any adverse effects on neighboring properties by the installation SITE PLANS of the proposed septic system. If you have any questions, or require additional information ROAD DESIGN for you /revy ew, please contact us. SOIL TEST A. Shafer, P.E. PERCOLATION 11 TEST RAS/JPW/LSU/lsu STRUCTURAL MECHANICAL INSPECTIONS ONSITE I WASTE WATER DISPOSAL SYSTEM DESION 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 SITE PLAN E!: v SCALE -44 1 nyO iso m rn o � 1 a m a1 N L 94 HCl �O I r H = cri O O T O y m :6 x C I otb Ak 0 n�'+O. ri Z m \ e m U~ � m r nvv \ O to O_O_ rrl �x' ,tio I W pn ZS nNO I \ .2 r- --536 j �' 536-� O � to 1 O y D-AU -- \ p EVERGREEN STREET ^' 0 o?�a ropmNN r soo�' IOTt py C Ain tn'' Ox Ori (n DOvw (/1 oHrr��-��pu n �Lr�••� ''+� ��tn•/ DSO (moi, C3 Ell ? to m mO '-�'U Ill �� • v i Vi a/ z of L n j ^! .• .�" �5 r O, E: a sf PROFILE Zo epi y ƒ ¥ . �CALE l t ` k , § 40 / k 0 Q Qi o " • ' & q m 20 / q $\ \ I �® 0 . / ; r \ ® , ° - � § ~& ~ i o e ■$� r=! Z&_Af PERFORMED Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street. Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST 1 LEGAL DESCRIP (• 1y'� (FEET) 1 stn /, 2- 3- 4- 5- 6- 7- 8- 9. 3456789 10 11 12- 13-4-1 14- 15- 16- 17- 18- 19- 2o4 4151617181920 COMMENTS C+'6/sM Z ,JOAA DATE Section: WAS GROUNDWATER ENCOUNTERED? IF AT WHAT DEPTH DEPTHT tkgh to Wax Mer Ualitoritlpt _ fplc 3 SITE PLAN Reading Date Gross Time Net Time Depth to Water Net Drop !to 10 tt 't .20 Io 3 �r 0 10 YO (d 3h t. PERCOLATION RATE J.IZ (minutestinth) PERC HOLE DIAMETER TEST RUN BETWEEN.S FT D 'S FT PERFORMED BY: Eagle River, Alaska 99571 CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDE5 IN EF CT ON THIS DATE. DATE: 72.008 (Rev. 4195) PERFORMED LEGAL DESCR -GK- .{::NGif11:ER'S SEAL) ; Municipality of Anchorage s �• x DEPARTMENT OF HEALTH & HUMAN SERVICES ," ••' °" ""�"� 825 "L" Street• Anchorage, Alaska 99502-0650 •••"-............y. •• SOILS LOG - P RCOLATION TEST t 'g bwi A. S`-mlo , '.• No. 1457-E ; o DATE PERFO MED: s �T �IliCtt= /D� BICC I Township, Range, Section: Municipality of Anchorage =w On -Site Water & Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL 01-1- n3- to G Parcel I.D. Al tT 7� Expiration Date: C� I 1. GENERAL INFORMATION Complete legal description FOREST RIDGE: BLOCK 1 LOT 113 Location (site address) Current Property owner(s) Mailing address Real Estate Agent 5301 BISHOPS CASTLE *ANCHORAGE, AK BARRY & KAREN MATTESON Day phone 5301 BISHOPS CASTLE *ANCHORAGE, AK 301-1521 TAMI TAYLOR W/ PRUDENTIAL Day phone 244-3504 2. TYPE OF DWELLING: N Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well . 4 �O Individual On-site Date of Payment.. Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ Received by: 1 1' Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $_ . 4 �O Waiver Fee $ Date of Payment.. '51"l/� (/ 3 6 Date of Payment Receipt Number._ oNe$G Receipt Number COSA # _ C) bC- I7 1110" Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, L1D. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 6. DSD SIGNATURE 1/ System #1 Approved for — 1�_ bedrooms. System #2 Approved for Disapproved. Conditional approval for bedrooms. f33,7—fi179 Date 66 /? bedrooms, with the following stipulations: ``����P��qY tOF((�C��r//i ON-SITE WATER AND WASTEWATER _ PP Original Certificate Date: ,I a — i 3 The Mirr(icipality or Aficho%a`ge Deve/op,emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the represenatations given in paragraph 5 by an independent professional civil engineer registered in the State ofAl,Iska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTCHMENTS: COSA Checklist Nitrate Advisory Septic System Advisory Arsenic Advisory' Well Flow Advisory Other (Rev. I M5) If more than 1 septic system is on the lot: COSA Checklist # _of_ Structure served by this system Certificate of On -Site Systems Approval Checklist 1 t3-12 Legal Description: FOREST RIDGE: BLOCK 1, LOT 1B Parcel ID: 017-4+4---* A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 4/12/93 Sanitary seal (Y/N) YES Total depth 101 ft. Cased to 101 ft. FROM WELL LOG Date of test 4/12/93 Static water level 18 ft. Well production 20 g,p,m. WATER SAMPLE RESULTS: nn Coliform U colonies/100 ml. Nitrate N—Ong./L. Arsenic: i�_JOug./L. B. SEPTIC/HOLDING TANK DATA Date of sample: 4/29/13 Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 12+ in. AT INSPECTION 4/29/13 18 ft. 5.65 g.p.m. Collected by: GEG. Ltd. Tank Type/Material STEP/STEEL Date installed 4/5-9/93 Tank size 1500 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (YIN) NO High water alarm (Y/N) YES Date of pumping 4/26/13 Pumper A+ HOME SERVICES C. ABSORPTION FIELD DATA Date installed 4/5-9/93 Soil rating (g.p.d./ft`or /bdrm) O.5 System type BED Length 50 ft. Width 24 ft. Gravel below pipe 0.5 ft. Total depth *3.16 ft. Eff. absorption area 1200 ft2 Monitoring tube YES Depression over field NO Date of adequacy test **4/29/13 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test E in. Water added**2660 gal. New depth E in. Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 600+ g,p.d, Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE If yes, give date - **PRE-SOAK AND TEST ON THE SAME DAY. D. LIFT STATION Date installed 4/5-9/93 Size in gallons 1500 Manhole/Acosss (Y/N) YES "Pump on" level at 43 in. "Pump off" level at 33 in. High water alarm level at 45 in. Datum BOTTOM OF TANK Cycles tested 3+ Meets alarm & circuit requirements? YES E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAift station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main Sewer /septic service line 25'+ Animal containment areas 50'+ Public sewer manhole%leanout N/A Holding tank Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineers Printed Name JEFFREY A. GARNESS Date SI3(3 (Rev. 11/05) . ........... G rness: O"y CE 7 53 A;.%3�f� A 7.58" 07 r ?p. S rn �7�49E' 00 ? 4� Op' 0 6 �' a o ac, � gN v 3 m N@ =Om c V w z-;Cg)g 46 14ms"� -44m ^' z�26 C, caC m o v r cxnoN �v (� m N 0 (n V c�pp z0 PL >rnovr-*inOm�m �O7 =fRo2vimmm z D z n r D A n m mm�gm�mo� °2 $ m0 z,�zi z0 o d yy 0 W) 0 2 000204 <0 rn 0 rnOO Z0 2 9 0 M O O M T ZrrC 010 MDC _ i rn-Ogn O U) O y to q=q z ,� v/rnjzO Xp0v m .iOlbs9 0� m c, �y • �yY A, 1 N 00003'19"W W O EVERGREEN STREE I I I I I I I f I I I I I I I I I I I I I I I I I I I I I I I 30' O X m O -�-I CCDV �r rnWM� J z N ED 01) z Q CT 1T1 �? e < m m `, O 4t Z 30' MUNICIPALITY OF ANCHORAGEAik B J 8 • �- DEPARTMENT OF HEALTH f£ HUMAN SERVICES AEMa Division of Environmental Services low On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. M O 1 n— 11 Q --1 L' 1. GENERAL INFORMATION Complete legal description Lot 1; Mch 1; FOREST -RIDGE SUBDIVISION i Location (site address or directions) I COLONY BUILDERS/SiU Tayfok Da hone 244-6233 Property owner Y P Mailing address 2340 Loren C.cn.c.Ce Anchwtage, AK 99516 Lending agency Day phone Mailing address Agent Day phone Address i Unless otherwise requested, HAA will be held for pickup. 14 2. NUMBER OF BEDROOMS: I 3. TYPE OF WATER SUPPLY: I XXX Individual well i Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. I 4. TYPE OF WASTEWATER DISPOSAL: (Individual on-site XXX Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 22-MM".1/21) Fro l MOA121 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verity that my• Investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure Indicated herein. l further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm s & s ENGIN 17034 Eagle Address Eagle Rivsry Engineer's signature 6. DHHS SIGNATURE 1)4_ Approved for bedrooms. Disapproved. Conditional approval for Additional Comments By: Phone y7 Date �..,;A OF •. Na. 1457•: bedrooms, with the following stipulations: Date 9— — 93 The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct Inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72cs(Fi«.1,11) B. woken ® Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ';F7L,cr-V- 1 c-oT 1 Parcel I.D. A. Well Data Well type ` "� If A, B, or C, attach ADEC letter. ADEC water system number V,P Log pre! e t (Y ) ` Date completed IZ CI Driller -NL:01 � Total depth /� lot Cased to 1 Dl / Casing height 1�v� Sanitary seat /N) Wires properly protectec 9C N) Y ,� FROM WELL LOG Date of test IZ Cj Static water level 8 Well flow 20 g.p.m. Pump levelt U - SEPARATION DISTANCES FROM WELL TO: AT INSPECTION ,77 SepticAwkfirtg tank on lot l oe�/ —;On adjacent lots 4- I ZS , bD-F' Absorption field on lot ; On adjacent lots Public sewer main Public sewer manhole/cleanout 0•►Ar-r Sewer service line 1 Petroleum tank 0 WATER SAMPLE RESULTS: Coliform 0 Nitrate Other bacteria 6 Date of sample: AJ I (01 `57;7 Collected by: S t;t.IC B. SEPTIC/HOLDING TANK DATA Date Installed 4kI ] 6i �j Tank size I J5OU S T�.� Compartments Z Cleanout N) Foundation cleanout Y/)Depres�si/an (Y& rJ High water alalam (Y N) Alarm tested( /N) / Date of pumping ,y b —Pumper,�- SEPARATION DISTANCES FROM SEPTICHGTANK TO: J Well(s) on lot D5 On adjacent lots 16Z-4- Foundation ,tom I To property line Absorption field —66' Water main/service line �D Surface water/drainage Ico '-1- 72-028(313)•FMMI ' I CONTINUED ON BACK PAGE C. LIFT STATION Date installed -6) ' oqv Manufacturer G1 iD �Lt r-1 K� Size in gallons I h�DO Manhole/Access ) Ven /N) 'Pump on" level at ?J 'Pump off" Level at High water alarm lev 1 L}� Cycles tested ?7 Meets MOA electrical codeo/N) SEPARATION DISTANCE FROM LIFT STATION TO: t Well on lot OS On adjacent lots i djj1-4- Surface water 001-4" D. ABSORPTION FIELD DATA Date installed '�'� Soil rating (GPD/Ft) 0'f57 System type f OuJ Length h0 Width Gravel thickness D CJ Total depth 2 Total absorption area (ZOO' ' t p esent 4) Depression over field (Y69 k-+ Date of adequacy test Olt- Results (pass/fall) t- u or Bedrooms Water level In absorption field before test KDk After test L.-) P Peroxide treatment (past 12 months) (Y&-- If yes, give date tJ! SEPARATION DISTANCE FROM ABSORPTION FIELD TO: I Well on lot ll -2-6 On adjacent lots I '�5p t - _'t- I Property line d / To building foundation '1 I To existing or abandoned system on lot KI O to 6 r t On adjacent lots :*a 4- Cutbank Water maintservice line 10 �— I 1 Surface water I 'r Driveway, parking/vehicle storage area I Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Pyr cc+b<�ti I. Signature �... rI' ;:...:h1 ♦ �9: f „x •. Awa ii ...'.>... rm Engin Date HAA Fee $ t5W - C- Waiver Fee $ Date of Payment Receipt Number 72-026 (3/97)' Back Date of Payment Receipt Number,